Professional Documents
Culture Documents
CPG Dementia Booklet
CPG Dementia Booklet
Levels
Levels of
of evidence
evidence and
and grades
grades of
of recommendation
recommendation
Levels of evidence
Level Type of Evidence
++
1 High quality meta-analyses, systematic reviews of randomised controlled
trials (RCTs), or RCTs with a very low risk of bias.
1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a
low risk of bias.
-
1 Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
++
2 High quality systematic reviews of case control or cohort studies. High
quality case control or cohort studies with a very low risk of confounding or
bias and a high probability that the relationship is causal
2+ Well conducted case control or cohort studies with a low risk of confounding
or bias and a moderate probability that the relationship is causal
-
2 Case control or cohort studies with a high risk of confounding or bias and a
significant risk that the relationship is not causal
4 Expert opinion
Grades of recommendation
Grade
Grade Recommendation
Recommendation
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
1
CLINICAL PRACTICE GUIDELINES
Dementia
2
Published by Ministry of Health, Singapore
16 College Road,
College of Medicine Building
Singapore 169854
ISBN 978-981-05-8095-7
Statementof
Statement ofIntent
Intent
3
Foreword
Dementia is the progressive decline in cognitive function due to damage or
disease in the brain. Essentially, dementia is a problem that makes it hard for a
person to remember, learn and communicate. With progression, it becomes
difficult for the person to take care of himself or herself. The disease extracts
its toll not only on its victims but also on the family and caregivers in terms of
physical, emotional and economic cost that translates into caregiver’s stress. It
is estimated that 44% of the total cost of dementia is due to informal care.*
According to the WHO data, nearly five million DALYs are lost each year
due to dementia in the Asia-Pacific Region. In Singapore, neuropsychiatric
illnesses are the leading cause of DALYs loss and dementia ranks 4th among
all neuropsychiatric illnesses. Dementia accounts for approximately 26,000
DALYs lost each year in Singapore.* As Singapore’s population is ageing
rapidly, it is projected that the prevalence (22,000 in 2005) of dementia would
double by 2020.*
The Ministry of Health released its first guidelines on Dementia in 2001 with
the aim of upgrading the skills of practitioners to conduct proper clinical,
functional and social assessment of the patients with and/or suspected of
having dementia. Since then, further evidence have emerged in the area of
therapeutics namely the role of cholinesterase in the treatment of dementia;
non-pharmacological methods for the management of behavioral and
psychological symptoms of dementia. It is thus timely to update this set of
guidelines.
Apart from updating the guidelines in the area of management, the guideline
also addresses ethical issues involved in the care of patients suffering from
dementia and the utility of genetic tests.
I hope this set of guidelines will assist all doctors involved in the care of
patients with dementia.
PROFESSOR K SATKU
DIRECTOR OF MEDICAL SERVICES
______________________
*Asia Pacific Members of Alzeimer's Disease International. Dementia in the Asia Pacific Region:
The epidemic is here. Alzeimer's Disease International 2006. Available at:
http://www.accesseconomics.com.au/publicationsreports/search.php?searchby=year&searchfor=2
006
4
Contents
Page
Executive summary of recommendations 1
1 Guideline development and objective 7
2 Introduction and epidemiology of dementia 8
3 Screening and assessment of dementia 11
4 Pharmacological management of dementia 25
5 Management of behavioural and psychological symptoms 37
of dementia
5
Executive
Executivesummary
summaryofofrecommendations
recommendations
Details of recommendations can be found in the main text at the pages indicated.
1
B A number of well-validated clinical criteria for the two most common
types of dementia (Alzheimer’s disease and Vascular dementia) have been
developed over the years. These can be used in the specialized dementia
clinics for the definition of Alzheimer’s disease and Vascular dementia
(pg 20).
Grade B, Level 2++
B Although high dose vitamin E (2000 IU per day) may have a modest
effect in delaying disease progression in moderately severe Alzheimer’s
disease, doses of vitamin E in excess of 400 IU a day should be avoided for
the treatment of Alzheimer’s disease until there is further data on its safety,
especially in patients with cardiovascular disease (pg 26).
Grade B, Level 1+
2
B Acetylcholinesterase inhibitors can be considered for the management of
A
moderate to severe Alzheimer’s disease (pg 28).
Grade B, Level 1+
3
B Practitioners who prescribe ginkgo for the treatment of dementia should
be aware of the unestablished benefit, variability of active ingredient among
preparations, and potential for drug interactions (pg 32).
Grade B, Level 1+
4
A Conventional and atypical antipsychotics may be used with caution,
given their side effect profile, to treat neuropsychiatric symptoms of
dementia (pg 39).
Grade A, Level 1+
B For patients with dementia with Lewy Body and behavioural problems,
acetylcholinesterase inhibitors should be considered first for management of
the behavioural problems (pg 42).
Grade B, Level 1+
5
Social and caregiver management of dementia and
community resources
GPP Where appropriate, respite care can be offered to relieve the burden
of caregiving on the family caregiver (pg 45).
GPP
GPP Referral to community resources to meet the care needs of the person
with dementia and his/her carer should always be considered (pg 46).
GPP
6
1 1 Guideline Development
Guideline Development and
and Objectives
Objectives
1.2 Objectives
The main aim of these guidelines is to provide an approach for
healthcare professionals to assess, evaluate and manage dementia
(using local evidence where possible).
7
22 Introduction
Introductionand
andEpidemiology
EpidemiologyofofDementia
Dementia
8
Table 1 Dementia prevalence in WHO world
regions8,9
Consensus dementia
prevalence (%) (60+)
Western Europe – EURO A 5.4
Eastern Europe low adult mortality – 3.8
EURO B
Eastern Europe high adult mortality – 3.9
EURO C
North America – AMRO A 6.4
Latin America – AMRO B/D 4.6
North Africa & Middle East EMRO 3.6
B/D
Developed Western Pacific – 4.3
WPRO A
China and developing Western Pacific 4.0
– WPRO B
Indonesia, Thailand and Sri Lanka – 2.7
SEARO B
India and S Asia – SEARO D 1.9
Africa – AFRO D/E 1.6
(Sources: Ferri CP et al, 2005; Kua EH, 1996)
9
Ethnic variations in dementia prevalence have also been
demonstrated with higher dementia prevalences among the Malays
(9.4%) and Indians (8.8%) as compared to the Chinese elderly
population (4.2%).7 With regards to dementia aetiology, Alzheimer’s
disease was found to be more common in Indians and Eurasians
while vascular dementia more common in Chinese and Malays.10 A
separate study found that among the elderly Malays, the prevalence
of vascular dementia was higher in women than men.11
10
10
3
3 Screening and
Screening and Assessment
Assessment of
of Dementia
Dementia
3.1 Screening
11
11
In evaluation patients who present with forgetfulness or confusion, it
is important to exclude delirium (acute confusional state) if this is of
an acute nature. If the forgetfulness or confusion is of a subacute
nature (weeks to few months), potentially reversible neurological
conditions and depression have to be excluded.
Subjective approach
12
12
Table 2 DSM-IV clinical criteria for diagnosis of
dementia17
13
13
Objective approach
14
14
(II) Assessing complications of dementia
a) Behavioural problems
15
15
assesses depression in dementia33 and has been shown to be a useful
screening instrument in our local population.34
b) Functional difficulties
c) Social problems
16
16
• The irreversible causes include degenerative causes
(Alzheimer’s disease, fronto-temporal dementia and dementia
with Lewy body), cerebrovascular disease (Vascular dementia),
prion-associated disorders (Creutzfeld-Jakob disease) and
neurogenetic disorders.
• The potentially reversible causes include infectious disorders
(meningitis and encephalitis), toxic or metabolic
encephalopathies (hypothyroidism, vitamin B12 deficiency, and
alcohol-related syndromes), neoplastic causes and
hydrocephalus (obstructive or normal pressure hydrocephalus).
Alzheimer’s disease
Vascular dementia
17
17
elderly population with prospectively evaluated dementia status,
Alzheimer’s disease-type and vascular pathology were the major
pathological correlates of cognitive decline but most patients had
mixed disease40, emphasising the important role of vascular
pathology in dementia.
DLB has been found in some studies to be the second most common
form of degenerative dementia, accounting for up to 20% cases in the
elderly. It is characterized by fluctuating cognitive impairment,
spontaneous parkinsonism and recurrent visual hallucinations.
Recognition of DLB is clinically important in view of the high
incidence (60%) of adverse and life-threatening reaction to
antipsychotics.
Fronto-temporal dementia
History
It is important to ask for the nature of the cognitive decline (sudden
or gradual), progression – either gradually progressive (more
suggestive of Alzheimer’s disease) or stepwise/fluctuating course
(suggestive of Vascular dementia). A history of significant alcohol
18
18
ingestion and medication use (such as antipsychotics,
antidepressants, anticholinergic agents and sedative-hypnotic agents)
and history of medical, neurological and psychiatric illness is
important.
Neuroimaging
19
19
• Functional neuroimaging techniques (Positron emission
tomography and single-photon emission tomography).
20
20
Appendix 1 Informant Questionnaire on Cognitive Decline
in the Elderly (IQCODE)21,22
Rated on 5-point scale from 1.
Much improved, A bit improved, Not much change, A bit
worse, Much worse [1ĺ5]
21
21
Appendix 2 Elderly Cognitive Assessment Questionnaire
(ECAQ)23
Items Score
Memory
1. I want you to remember this number. 1
Can you repeat after me (4517). I shall test you
again in 15 min.
2. How old are you? 1
3. When is your birthday? OR in what year were you
born?
Orientation and information
4. What is the year? 1
5. date? 1
6. day? 1
7. month? 1
8. What is this place called? Hospital/Clinic 1
9. What is his/her job? (e.g. nurse/doctor) 1
Memory Recall
10. Can you recall the number again? 1
Total
22
22
Appendix 4 Chinese Mini Mental State Examination
(CMMSE)25
Items Score
What day of the week is it? 1
What is the date today? 1
What is the month? 1
What is the year? 1
Where are we now? 1
What floor are we now? 1
In which estate are we? 1
In which country are we? 1
Repeat the following words: “Lemon, Key, Balloon” 3
Substract $7 from $100 and make 5 subtractions 5
Can you recall the three wods 3
What is this? (show a pencil) 1
What is this? (show a watch) 1
Repeat the following:
a) “No ifs, ands or buts” (English) 1
b) “Forty-four stone lions” (Chinese)
Follow 1 3-stage command:
“Take this piece of paper, fold it in half, and put it on the 3
floor
Say a sentence of your choice 1
Read and obey what is written on this piece of paper
“Raise your hands” 1
Copy this drawing on a piece of paper 1
Total score
23
23
Appendix 5 Functional complications of dementia35
Variable Questions
Community Can patient find his way around in unfamiliar
functioning surroundings, manage his finances, do shopping
or marketing?
Home-care functioning Can he prepare his own food, help in housework
and cooking? Is he able to choose proper attire to
dress himself? Is he safe to be left at home alone?
Self-care functioning Is he able to bathe, dress himself? Is he able to go
to toilet, transfer or feed himself? Is he continent
of bladder and bowels?
(Source: MS Chong et al, 2003)
24
24
4
4 Pharmacological Management
Pharmacological Management of
of Dementia
Dementia
4.1 Overview
GPP Pharmacotherapy should be part of a multi-pronged strategy to
dementia management that encompasses a well-established
diagnosis, education of patient and caregiver, non-pharmacological
measures and comprehensive caregiver psychosocial intervention.
GPP
25
25
When significant neuronal damage has occurred, treatment of
potentially reversible causes often arrests the underlying
pathophysiology but may not reverse the dementia. Only a small
percentage of potentially reversible abnormalities are completely
reversible, and the more common of such conditions are
hypothyroidism and vitamin B12 deficiency.55 An increasing body of
evidence suggests that vascular risk factors are putative not only in
vascular dementia (VaD), but also in Alzheimer’s disease (AD)56,
thus, vascular risk factors (such as hyperlipidemia, hypertension,
diabetes mellitus, atrial fibrillation, smoking) should be sought for
and managed in all dementia cases.
26
26
A Anti-inflammatory agents (such as non-steroidal anti-
inflammatory agents and cyclo-oxygenase 2 inhibitors) are not
recommended for the prevention of cognitive decline in Alzheimer’s
disease.60, 61
Grade A, Level 1++
27
27
lasting one year or less in duration) involving the use of donepezil,
rivastigmine or galantamine that are conducted in patients with mild
to moderate Alzheimer’s disease consistently demonstrate modest
improvement in (1) cognition and global functioning (on average, a
3-point difference on the 70-point Alzheimer’s disease assessment
scale over a 6-month period), (2) activities of daily living and (3)
neuropsychiatric symptoms (delay in emergence of symptoms,
improvement in apathy, and variable patterns of improvement for
milder degrees of anxiety, depression and hallucination).70-72 It is
unclear whether AchEI therapy confers benefit in terms of reducing
time to institutionalisation.73 The duration of benefit may persist as
long as three years in some patients.74
28
28
Deficient cholinergic neurotransmission has been postulated to
contribute to the cognitive impairment of vascular dementia. Two
randomized, double-blind, parallel-group, placebo-controlled trials
with a total of 1,219 people suffering from mild to moderate
probable or possible vascular dementia have been published.80,81
Donepezil, at doses of 5 or 10 mg a day was compared with placebo
for 24 weeks. A meta-analysis that includes these studies showed
that the donepezil treated patients had a statistically significantly
improvement in cognitive outcome compared to placebo treated
patients on the cognitive subscale of the Alzheimer's Disease
Assessment Scale (ADAS-Cog) as well as on the Mini-Mental State
Examination (MMSE) at 12 and 24 weeks at both doses. However,
in terms of global function and activities of daily living, patients
showed a less uniform dose response.82
Donepezil was well tolerated; most of the side effects were transient
and were resolved by stopping the medication.
Thus, AchEI have been shown to be effective and safe for the
treatment of cognitive symptoms in vascular dementia. However, no
AchEI has been licensed for the treatment of vascular dementia due
to concerns as to the aetiological heterogeneity of patients included
in the trials as well as lack of consistent effects on domains other
than cognition.
29
29
Consistent with the neurobiochemical profile of cholinergic deficit in
DLB, a study of 120 DLB patients reported that rivastigmine
significantly reduced the core psychiatric symptoms of apathy,
anxiety, delusions and hallucinations while enhancing cognitive
performance in tasks with a substantial attentional component,
without worsening the motor symptoms of Parkinsonism.84,85
Similarly, in Parkinson’s disease dementia, a rivastigmine study of
541 patients reported modest improvements in cognition mirroring
the degree seen in Alzheimer’s disease, as well as benefits in
activities of daily living and neuropsychiatric features.86 Although
generally well tolerated, there were significantly more cholinergic-
mediated adverse events such as nausea, vomiting and tremors in the
treated group.86
30
30
To reduce intolerability to gastrointestinal adverse effects, AchEI are
often started at lower doses (donepezil 2.5 mg/day; rivastigmine 1.5
mg twice daily; galantamine 8 mg/day) (Table 4). Studies have
consistently shown that patients who received recommended doses of
AchEI exhibited better outcomes than those who received placebo or
lower doses.70-72 Thus, where tolerated, AchEI should be gradually
titrated to recommended doses (5-10 mg/day donepezil; 6-12 mg/day
rivastigmine; 16-24 mg/day galantamine) over 4-8 weeks.
31
31
The initial dose of memantine is 5 mg once a day, with 5mg
increments at intervals of at least one week until a maximum of 10
mg twice a day is achieved (Table 4). It should be used with caution
in patients with epilepsy and renal impairment, and the clinician
should be aware of interactions involving commonly prescribed
medications such as dextromethorphan and L-dopa.
Thus, memantine has been shown to be effective and safe for the
treatment of cognitive symptoms in vascular dementia. However,
memantine has not been licensed for the treatment of vascular
dementia due to concerns as to the aetiological heterogeneity of
patients included in the trials as well as lack of consistent effects on
domains other than cognition.
32
32
agents, and the antagonism of thiazides and anticonvulsants
(valproate and carbamazepine).103
33
33
For many, the diagnosis of dementia can be devastating and thus,
individuals with dementia and their family may have high,
sometimes unrealistic, expectations of any treatments offered. It is
therefore important to communicate with the patient and his
caregiver/family from the onset that54,106:
- The medications are not a cure.
- The medications may not work for everyone.
- Although there may be a response in terms of modest
improvement or stabilization of symptoms, symptomatic therapy
ultimately does not prevent progression of disease and cognitive
decline will continue even with treatment.
- The medication may be discontinued if the patient does not
respond after an adequate trial of 3-6 months.
34
34
Stabilisation or modest improvement above baseline may be
observed in the first 6-9 months, which can be monitored by the use
of106,107:
(i) clinical methods, via assessment of cognitive, functional and
behavioural domains through interview with the patient and
caregiver; and/or
(ii) standardized rating scales, which involves either:
a. brief mental status tests such as the Chinese Mini Mental
State Examination (CMMSE), Abbreviated Mental Test
(AMT) and Elderly Assessment Cognitive Questionnaire
(ECAQ), or
b. more detailed psychometric testing. After 6-9 months, a
lesser decline can be observed, which can be documented by
patient and caregiver interview for cognitive, functional and
behavioural (emergence of neuropsychiatric symptoms)
features.107
35
35
Table 4 Dosing information of dementia drugs in
clinical use
Medication Forms Dosing Starting Recommended
interval dose dosing
(1) Cholinesterase inhibitors
Donepezil Tablet (5 mg, 10 Once daily 2.5-5 mg 5-10 mg/day
(Aricept®) mg) once daily
36
36
5 5 Management of
Management of Behavioural
Behavioural and
and Psychological
Psychological
Symptoms of
Symptoms of Dementia
Dementia (BPSD)
(BPSD)
First, the direct impact model whereby the behaviours are seen to be
the direct result of brain pathology. Second, the unmet needs
model108, where unmet physical, emotional, spiritual and
idiosyncratic needs underlie challenging behaviours. Behaviour is
seen as a means of communication, a “cry for help” to fulfill a basic
human need. Third, the behavioural model109,110 assumes
connection between Antecedent, Behaviour and Consequence of the
behaviour (ABC model), where antecedents operate through stimulus
control, and the consequences reinforce behaviour. Modification of
the behaviour would thus entail changing the antecedents and/or the
consequences. Last, the concept of progressively lowered stress
threshold111 (PLST) holds that dementia results in greater
vulnerability to the environment, where minor stressors can
precipitate anxiety, agitation and even a catastrophic reaction
because the person with dementia is more susceptible and less able to
cope with stressors or triggers in the environment compared to
cognitively normal elderly individuals. Often, more than one model
is needed to explain the problematic behaviour in question.
37
37
NPT are multifaceted and varied, and one form of intervention can
bring about a broad range of effects. The appropriate NPTs are
instituted when a good understanding of the issues behind the
behaviour is procured. The following categories of NPT are
noteworthy but this list is not exhaustive:
1) Medical/nursing care interventions, e.g. pain management, relief
of fecal impaction and urinary retention, removal of restrainers,
enhanced care methods such as person-centred showering and
towel bath.
2) Environmental interventions, e.g. dementia safe and friendly
environments, wandering paths, natural or enhanced
environments, merry-walker.
3) Activities, e.g. structured activity programmes, physical
rehabilitation and physical exercises.
4) Social contact, e.g. one-on-one interaction, pet therapy,
simulated presence.
5) Timalation (interaction in which the senses are the main focus
for engagement rather than interactions which involve an
intellectual or emotional component), e.g. music, aromatherapy,
massage, dance and movement, multi-sensory approaches such
as snozelen.
6) Standard psychological therapies, e.g. behavioural therapy,
validation, resolution, reality orientation, reminiscence.
7) Alternative therapies, e.g. art therapy, bright-light therapy.
8) Staff training.
38
38
5.2 Pharmacological interventions to manage BPSD
5.2.1 Antidepressants
5.2.2 Antipsychotics
Conventional antipsychotics
Conventional antipsychotics have been used to treat behavioural
problems associated with dementia. There is evidence for slight
benefit of haloperidol over placebo for treatment of aggression.
However, adverse events of extrapyramidal side effects and
somnolence may limit its routine use.113 Low-potency antipsychotics
like chlorpromazine should be used with caution in view of postural
hypotension and anticholinergic side-effects.
Atypical antipsychotics
The atypical antipsychotics, olanzapine and risperidone have been
shown to be modestly effective in the management of behavioural
39
39
problems in patients with moderate to severe dementia at doses of
olanzepine at 5-10 mg/day and risperidone 1.0 mg/day.113-115 There
is some evidence of quetiapine at doses of 25-100 mg/day showing
improvement in agitation scores.115,116 In frail elderly patients,
titration of dosage should be based on individual responses, starting
at the lowest possible dose with gradual increments.
5.2.3 Trazodone
40
40
One small randomised controlled trial showed reduction in agitation
when accompanied by depressive symptoms in patients with
dementia.122
5.2.5 Benzodiazepines
There is no evidence of the efficacy of benzodiazepines in the
treatment of behavioural problems associated with dementia.
41
41
In view of the potential adverse effects associated with antipsychotic
therapy, non-pharmacological interventions and identification of pain
and other environmental factors should be assessed and managed
accordingly.
42
42
Figure 1 Algorithm for management of
neuropsychiatric symptoms of dementia
Patient with dementia and a behaviour problem
Evaluate for and manage delirium, pain, other medical and environmental causes of behaviour
Does patient have symptoms of depression or anxiety? Yes Monitor for recurrence
No
Yes
Behaviour problem improved? Yes
43
43
6 6 Social and
Social and Caregiver
Caregiver Management
Management of
of Dementia
Dementia
and Community Resources
and Community Resources
44
44
Several caregiver interventions have yielded promising results, the
NYU spouse-caregiver intervention14,124,125 and the REACH126
(Resources for Enhancing Alzheimer’s Caregiver Health) initiative
are noteworthy. They have been shown to reduce caregiver burden
and depression, ease caregiver reaction to behavioural problems and
delay nursing home placement. A meta-analysis127 also found that
counselling and training caregivers in how best to care had
moderate, statistically significant results. Multi-component
interventions have a greater effect than narrowly focused ones. A
support system that can meet the individual needs of different
caregivers, and be able to provide on-going support that is
responsive and continuous is most beneficial.
Respite care can take place in the home of the person with dementia
or a daycare centre. It may also vary in terms of who provides care;
trained staff, relatives of the patient or volunteers. The care provided
can also differ in duration, ranging from a couple of hours to weeks.
Caregivers often express the need for respite to allow them sometime
to rest, rejuvenate and have some moment to themselves. Although
the few trials performed have not shown improvements in caregiver
burden, improved caregiver satisfaction is reported.131,132 A
systematic review133 failed to show any benefit in caregiver outcomes
but as the review was only based on 3 studies that met inclusion
criteria, this reflects the lack of high quality research rather than an
actual lack of benefit.
45
45
6.2 Community resources
46
46
7 7 Ethical Issues
Ethical Issues in
in Dementia
Dementia
7.1 Preamble
Dementia is a clinical syndrome characterized by global cognitive
decline and impairments, which result in a loss of a patient’s
individuality and autonomy. At different stages, the disease causes
different extents of functional decline, and different severities in
behavioural and psychiatric symptoms. The disease also results in
varying extents of impairments in decision-making capacity, and at
some point, a patient becomes mentally incompetent and ceases to be
an autonomous agent.
7.2 Decision-making
1. Respect for autonomous decision making is a fundamental
ethical and legal right of a mentally competent individual. This
right of self-determination should be respected to the fullest
possible extent, even in dementia or conditions associated with
cognitive impairment.
2. When affected by dementia, the key to a patient’s right of
autonomy is the presence of adequate decision-making capacity.
As a patient’s cognition and hence functional abilities for
decision making is impaired in dementia, a patient may or may
47
47
not possess adequate decision making capacity to make an
informed choice.
3. A diagnosis of dementia per se, however, does not automatically
imply a loss of decision making capacity, which is specific to
each patient and to each medical decision. Therefore, those who
cannot comprehend complex situations may still possess the
capacity to make simple decisions, or to convey their opinions
regarding the burdens and benefits of ongoing treatments.
4. In deciding if a patient with dementia possesses adequate
capacity with respect to making a particular decision, a clinical
evaluation of the following functional abilities should be
made137:
a. Ability to express a choice
b. Ability to understand information provided
c. Ability to appreciate significance of information and
relevance to self
d. Ability to manipulate information rationally before arriving
at a decision
5. If the patient lacks adequate decision making capacity, the
ethical imperative switches to one that aims to protect the patient
from his or her own harmful decisions or actions. Patients must
not be under-treated nor forced to receive inappropriate
treatment just because they lack decision making capacity or
legally appointed guardian(s). Consideration of the patient’s
functional status and quality of life is vital in making treatment
decisions for the patient.
6. In Singapore, treatment decisions for a patient who is incapable
of giving a valid consent will be made:
a. in immediate, life threatening emergencies by doctors, based
on the principle of medical necessity
b. in less emergent situations, by:
i. legal guardian (Committee of Person) appointed under the
Mental Disorder and Treatment Act (Cap 178, 1985 Rev
Ed)138
ii. the doctor, in accordance to principle of best interests (in
the absence of any legally appointed guardian).
Nevertheless, this does not exempt the doctor from
communicating with patient’s family members and
caregivers, so as to incorporate patient’s known values
and established preferences in the determination of
patient’s best interests. The opinions and sentiments of
48
48
the patient’s family ought to be sought, but they are not
legally binding.139
7. For patients adjudged clinically to have permanent and global
decisional incapacity as a result of dementia, decisions about
health care will be recurrent over their remaining lifetime.
Therefore, when such issues arise, the attending physician may
wish to consider a formal application should be made to the
High Court for the declaration of mental incompetence and for
the formal appointment of guardianship (committee of person(s)
and committee of estate) under the provision of the Mental
Disorder and Treatment Act (MDTA).
APOE ε4
3. There is a body of evidence that APOE ε4 is strongly associated
with late-onset Alzheimer’s Disease (AD) and that when present
may represent an important risk factor for the disease. However,
at the present time, it is not recommended for use in routine
clinical diagnosis nor should it be used for predictive testing.
a. APOE genotyping does not provide sufficient sensitivity or
specificity to be used alone as a diagnostic test for AD.141 It
is therefore not recommended as a diagnostic tool in routine
clinical evaluation of patients for sporadic early- and late-
onset AD.136,141-147
b. Based on presently available data, APOE genotyping is not
established as a predictive marker of AD. Furthermore,
49
49
APOE testing does not provide any medically useful
information linked to treatments that are effective in
preventing or delaying the onset of disease. Therefore,
susceptibility testing in asymptomatic individuals is not
recommended and may be associated with potential
psychological harm.136,142-144
7.4 Driving
1. Driving a motor vehicle is a complex task that requires the
simultaneous and coordinated application of different cognitive
abilities including ability to recall and apply traffic rules, sound
judgement, attention span, and quick responses. A person’s
ability to drive safely can therefore be affected in dementia,148,149
with consequently higher risk of accidents.150,151
2. Driving also represents independence, freedom and mobility.
The issue of driving in dementia requires therefore the balancing
of individual freedom and patient confidentiality on one side
versus public and patient safety on the other.152
3. Dementia adversely affects driving performance even in its mild
stages, although some persons with late-onset Alzheimer’s
disease DAT appear capable of driving safely for some time
after disease onset.148 A diagnosis of dementia therefore does not
automatically mean that a person is incapable of driving.148,153,154
The decision should be based on dementia severity or a
demonstration of impaired driving competence.148
4. Longitudinal data suggests that driving performance deteriorates
as the severity of dementia progresses over time,155 primarily in
early dementia. In one study, drivers with AD at a severity of
CDR 1 were found to pose a significant traffic safety problem
both from crashes and from driving performance
measurements.148
5. In patients with mild to moderate dementia, physicians find it
difficult to identify which individuals should not drive.
Performance-based measures of driving skills, such as on-road
driving tests, are recommended as a means of assessing driving
competency.156,157 A traffic-interactive, performance-based road
test that examines cognitive behaviours provides an accurate and
reliable functional assessment of driving ability.148
6. Even if a driver with early dementia passes a road test,
progression of the disease is expected to lead to deterioration in
driving skills.155 Therefore, repeat road testing at regular
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intervals, usually 6 to 12 months, or earlier if suggested by
significant cognitive decline, is important.
7. For patients who are assessed to be unsafe for driving, doctors
should enlist the help of family members to persuade patient to
stop driving. To encourage such patients to surrender their
driving licences, alternative forms of transport should be
arranged, where possible.158 If the patient is absolutely inflexible
and insists on driving, thereby creating a reasonable risk to
public safety, it is then ethically and professionally permissible
for the doctor to breach doctor-patient confidentiality and file a
report to the relevant licensing authorities.136 Other measures
deemed to be ethical include hiding the patient’s car keys or
immobilising the car if necessary.159
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discussion on treatment options and available support services
both in the hospital and the community.
4. After the diagnosis has been communicated, the patient and
family should be given time to process the information and to
come to terms with it. They should be given ample opportunity
to ask questions and seek clarification from the doctor.
5. The objectives of truthful disclosure of diagnosis to patients
with dementia are to empower the patient with: the courage to
request for information, the cognition to understand
information and the strength and resources to cope with the
burden of information.
7.6 Restraints
1. Restraints, whether environmental, physical or
pharmacological, are used in the management of patients with
dementia to restrict or control the patient’s movement or
behaviour that may compromise the safety of the patient and/or
others.
2. However, the use of restraints is not without potential
problems:
a. Risk of harm and injury
b. Decrease in ability to perform cognitive and physical
activities, thereby resulting in cognitive and functional
decline, and ultimately loss of independence
c. Loss of freedom, leading to loss of confidence and self-
esteem
3. The preferred choice should therefore be to avoid the use of
restraints. Restraints should not be a substitute for a proactive
search for reversible precipitating factors for patient’s
behavioural problems, or for good communication with the
patient.
4. If restraints have to be used on a patient, it should be seen as a
temporary means and should be stopped as soon as the
indication is no longer present. Excessive use of restraints
should be avoided - any restraint should therefore be instituted
for the minimal period of time and at the minimal strength or
degree needed to achieve the intended outcome for the patient.
The patient should also be carefully monitored while on
restraints.
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7.7 Living alone
1. Many patients diagnosed to have dementia continue to insist on
living alone. In some of these patients, cognitive decline arising
from dementia leads to poor compliance with medical treatment,
lack of safety awareness and poor judgement. All these can pose
a risk to the safety and well-being of the patient. The patient
may also be exposed, as a result, to mistreatment, fraud and
exploitation by others.
2. A diagnosis of dementia does not automatically mean that the
patient is incapable of living alone. This decision should be
based on an assessment of the patient’s decision making capacity
with respect to placement, and ability to continue living alone in
the community without posing too much risk to self and to
neighbours. Considerations should also be given to the potential
negative social and physical impact of moving from a familiar
environment to institutional care.
3. If the patient is assessed to have adequate decision making
capacity and insists on living alone, the health care professionals
should then support the decision by simplifying the daily tasks at
home and using available community resources. The patient
should also be reassessed as the dementia progresses and erodes
both his decisional capacity and ability for self-care.
4. If the patient has doubtful decisional capacity, then there should
be an assessment, preferably with the occupational therapist, on
the following: safety to self and to neighbours when carrying out
activities of daily living and tasks such as food preparation,
handling of monies, laundry and compliance to medication.
5. The final objective is to provide the patient with dementia with a
safe, familiar and comfortable living environment, and to avoid
premature institutionalisation.
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8 8 Cost-effectiveness
Cost-effectiveness
54
54
9
9 Clinical Quality
Clinical Quality Improvement
Improvement
55
55
Annex
Annex 11
56
56
Dementia day care centres
57
57
Nursing homes with dementia facilities
1 Apex Harmony Lodge 10, Pasir Ris Walk Tel. 65852265
Singapore 518240 Fax:65852982
58
58
Training in dementia
1 Alzheimer’s Disease Blk 157, Lorong 1, Toa Tel: 63538734
Association ( including Payoh Fax: 63538518
domestic helpers) #01-1195
Singapore 310157
Home-based care
1 Aged Psychiatry 10 Buangkok View Tel. 63892175
Community Assessment Singapore 539747 Fax: 63851051
and Treatment Service
Institute of Mental
Health
Department of Geriatric
Psychiatry
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Self-assessment (MCQs)
Self-assessment (MCQs)
After reading the Clinical Practice Guidelines, you can claim one CME
point under Category III (Self-Study) of the SMC Online CME System.
Before you login to claim the CME point, we encourage you to evaluate
whether you have mastered the key points in the Guidelines by
completing this set of MCQs. This is an extension of the learning process
and is not intended to “judge” your knowledge and is not compulsory.
The answers can be found at the end of the questionnaire.
2. Diagnosis of dementia
A) Dementia can be diagnosed clinically using DSM-
IV criteria for dementia.
B) The patient can be diagnosed with dementia if he
has memory impairment and deficits in one other
cognitive domain (agnosia, aphasia, apraxia and
executive functioning) although these cognitive
declines do not impair social or occupational
functioning.
C) Brief bedside screening instruments (such as
ECAQ, AMT, CMMSE) may be used to aid in the
diagnosis of dementia.
D) Neuropsychological testing is useful in detecting
subtle cognitive difficulties not picked up by brief
screening instruments.
E) Potentially reversible causes of dementia should be
excluded in all patients who meet DSM-IV criteria
for dementia.
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3. Complications of dementia
A) Patients with dementia may present with anxiety
and depression in the early stages of their illness.
B) Caregivers of dementia patients with significant
behavioural problems may experience coping
difficulties and caregiver stress.
C) Patients with dementia first experience difficulties
in home functioning.
D) Behavioural problems occur uncommonly in
patients with dementia.
E) Depression, agitation, anxiety, paranoia,
hallucinations and sleep problems should be asked
for routinely in patients with dementia.
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6. Management of behavioural and psychological symptoms
of dementia
A) Pharmacological measures should be instituted
initially for management of behavioural and
psychological symptoms of dementia.
B) Non-pharmacological methods to manage
behavioural symptoms of dementia entails
understand the aetiology of the behaviour and
addressing the problem at its root cause.
C) Antipsychotics (conventional or atypical) should be
used as first line in pharmacological treatment of
dementia.
D) Antidepressants may be used to treat comorbid
depression in dementia.
E) Typical antipsychotics is more efficacious
compared to atypical antipsychotics.
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Answers
1 (a) T 5 (a) F
1 (b) F 5 (b) T
1 (c) T 5 (c) F
1 (d) T 5 (d) T
1 (e) T 5 (e) F
2 (a) T 6 (a) F
2 (b) F 6 (b) T
2 (c) T 6 (c) F
2 (d) T 6 (d) T
2 (e) T 6 (e) F
3 (a) T 7 (a) F
3 (b) T 7 (b) T
3 (c) F 7 (c) T
3 (d) F 7 (d) T
3 (e) T 7 (e) T
4 (a) T
4 (b) F
4 (c) T
4 (d) F
4 (e) T
80 80
Workgroup members
Workgroup members
Members
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Subsidiary editors
Dr Pwee Keng Ho
Assistant Director (Health Technology Assessment)
Health Services Research & Evaluation Division
Ministry of Health
Dr Rajni Gupta
Executive (Health Technology Assessment)
Health Services Research & Evaluation Division
Ministry of Health
Acknowledgement:
Dr Miny Samuel
Senior Evidence-Based Medicine Analyst
and
Co-Director of the Singapore Branch, Australasian Cochrane Centre
Clinical Trials & Epidemiology Research Unit
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ISBN 978-981-05-8095-7